The CDC’s Mission Impossible

The Wall Street has a new exclusive story about the incoming head of the CDC, Rochelle Walensky, and her plans to greatly increase vaccination rates and restore faith in the agency.

Dr. Walensky has an impressive background: the recent head of infectious diseases at Mass General, one of the top teaching hospitals in the US, where she was also a member of state advisory panels on Covid policy. Some questioned her elevation due to her lack of public health or CDC experience. Walensky said she was surprised to get the nod and assumed her outsider status was a big reason why.

Dr. Walensky will presumably be implementing the Biden Adminstration’s Covid-19 vaccine plans. Given Dr. Walensky’s not anticipating that she would be offered the leadership of the CDC, one has to assume she was not meaningfully involved in the development of this program.From WebMD’s summary, based on an announcement a few days ago:

Biden outlined five major goals:

  • Work with states to expand eligibility to anyone age 65 or older, and to essential workers, while continuing to vaccinate health care workers.
  • Set up thousands of new federally-supported mass vaccination centers at gyms, stadiums and other locations—with 100 by the end of his first month in office– supported by the Federal Emergency Management Administration. FEMA will mobilize thousands of staff and contractors to work with state and local teams and the National Guard.
  • Deploy mobile vaccination clinics to hard-to-reach underserved urban and rural areas, relying in part on community-based physicians.
  • “Jumpstart” a federal partnership with pharmacies to increase capacity at chains and independent outlets.
  • Use the Defense Production Act to help ensure uninterrupted production and delivery of vaccine and vaccine supplies. The aim is to release most vaccine supply when available, while keeping a small reserve to cover unforeseen shortages or delays.

Other elements were more napkin-doodles. Again from WebMD:

The Biden plan would encourage states to allow additional qualified professionals to give vaccines. Biden said he envisions using military health care professionals, FEMA employees and staff from the U.S. Public Health Service Commissioned Corps to help expand the number of people who can give vaccines. He also said he would seek to allow certain qualified professionals, including retired medical workers who are not licensed to administer vaccines, to do so with appropriate training….

He said that addressing vaccine hesitancy will also be a priority and will be done through a “massive public education campaign to rebuild that trust, to help people understand what science tells us—that vaccines help reduce the risk of COVID infections”.

This is very ambitious, since it involves coordinating across Federal agencies, with state and local governments, hospitals, and major pharmacy chains. And at the same time, Walensky also plans to address the CDC’s damaged reputation. From the Wall Street Journal:

Dr. Walensky vowed to restore public trust in the CDC, which surveys show sagged after the Trump administration interfered in decision making and the agency made its own mistakes, such as botching the rollout of a diagnostic test for detecting Covid-19…

The CDC will hold regular press briefings, release current data, and will announce changes in recommendations, said Dr. Walensky, who is moving on Friday to Atlanta, where the CDC is based. “There will be way more communication, the science will be out there,” she said.

She said she may seek an external review of how the CDC’s Covid-19 diagnostic test was botched, which hampered testing for the virus in the crucial initial weeks it was spreading in the U.S.

Also among her top priorities, she said, are strengthening the nation’s public-health departments, which have suffered from years of funding and staff cuts, and modernizing the CDC’s outdated data systems.

Those steps will require substantial new funds from Congress. “I plan to be there often,” she said.

“We need to build a sustainable public-health infrastructure across the country, because one of the reasons that we’re in this mess is because we didn’t have it,” she said.

While it may seem churlish to express reservations at such an early stage, and it would be better if we were wrong, there are reasons to harbor doubts.

Poor operational competence and capacity in large swathes of the public and private sectors. It is impossible to describe this overarching impediment in strong enough terms, so forgive me for the very short form treatment. We are suffering the consequences of decades of rule by MBAs and lawyers. Fetishizing efficiency over safety has resulted in a reduction in hospital beds. Many hospitals have outsourced their emergency room staffing to private equity, giving rentiers a choke point on a vital public health issue.

And that’s before getting to the widespread adoption of practices in private sector that reduced the discretion and therefore competence of low-level and supervisory staff. This is the level of worker whose motivation and judgement calls are essential in emergency responses. Yet the US has had three decades plus of working to deskill their jobs in order to cut their pay.

Trump wasn’t crazy to talk about using the military to help with the vaccine rollout. They have unmatched skills in logistics. But the armed services made it very clear they weren’t interested in the vaccine tar baby. Trump lacked the credibility and cojones of some earlier Presidents to call them to his office and give them their marching orders.1

Magnitude of CDC role relative to Dr. Walensky’s previous experience. Walensky has never managed a bureaucracy the size of the CDC, which has 21,000 employees. It’s a little troubling that there is no “infectious diseases” department on the Mass General org chart from June 2019.2 That confirms the concern that she does not have a history of running a large or even a not-so-large operation. Nor has she designed or overseen the implementation of large-scale program. This challenge is even more daunting given the need for rapid execution to accelerate vaccine distribution.

Some people step up successfully to battlefield promotions. A high profile example was when Elizabeth Warren started up the CFPB. There was nothing in her background to suggest that she could execute an administrative task of that magnitude, let alone in six months.3 But this is an even bigger skill jump.

And keep in mind another issue: Dr. Walensky is going from an elite organization to one where she’ll deal with top managers and numerous important outside constituencies who won’t be at the same level, intellectually and likely in terms of professionalism, of her former colleagues. This is another difficult adjustment.

Existing CDC weaknesses. The test fiasco wasn’t the only CDC failure. From STAT in April:

While individual states oversee their public health departments, provision of health care, and actually implement policies and programs, the CDC has always provided the intellectual leadership, technical expertise, the expert guidance that states rely on to do their work. This federal agency coordinates efforts across states so they can learn from one another. And the CDC standardizes data and methods so we can get a true national picture of what is happening….

Want to know how many tuberculosis cases there were in the U.S. last year? Ask the CDC. Want to know about health-care-associated infections? Ask the CDC. It knows.

But ask how many Covid-19 tests have been done, and the CDC’s doesn’t have an answer. Want a daily update on how many people are getting hospitalized for Covid-19? The CDC isn’t tracking it. Want to know if social distancing is making a difference? The CDC doesn’t know.

During this pandemic, when accurate, timely, nationwide information is the lifeblood of our response, the CDC has largely disappeared.

The performance of the world’s leading public health agency has been surprising, and by that I mean surprisingly disappointing….

Beyond its testing failure, the CDC has been slow and its response inadequate in another area where it has always excelled: evidence-based guidance…

The agency was slow to suggest that we should end large gatherings. As masks for health care workers became scarce, it recommended that health care workers wear bandanas and scarves with zero evidence that these would protect workers from the virus. Investigative reporting has uncovered unclear and disorganized communication to state public health agencies. And the CDC’s restrictive early testing guidelines did not necessarily align with what was understood about disease symptoms and risks at the time.

The reason for the lengthy excerpt is to serve as a reminder of what the CDC’s role is: a data/research organization to inform state and local public health initiatives. Dr. Walensky does want to address these shortcomings, but it’s not clear how high these issues are on her to do list.

Massive mission expansion. Disturbingly, the Biden Administration looks to be intent on having the CDC play a significant role in vaccine distribution, when it couldn’t even get something in its wheelhouse, Covid test kits, right. Giving a poorly performing bureaucracy a whole heap of new responsibilities that are way outside its historical scope is a prescription for failure.

Dr. Walensky confirmed that the CDC will attempt to play a much more hands-on role. The Journal article admittedly discusses the broader Biden strategy first without clarify what will fall, say to HHS versus the CDC. However, as I read this, Dr. Walensky seems to be using the CDC “we” as opposed to the Biden Administration “we” with respect to mobile clinicsFrom the Journal:

The incoming administration of President-elect Joe Biden plans to accelerate vaccinations by boosting supplies, matching the number of people who are eligible for vaccines to the number of doses available and hiring retired health-care workers, public health officers and others to administer the shots.

The plan also includes making vaccines easier for people to get, particularly those in underserved communities.

“We want to do mobile clinics, because not everybody is going to be able to get to a stadium,” Dr. Walensky said. “We want to bring those clinics to the people, to the communities where they otherwise wouldn’t have had adequate outreach.”

Mobile clinics sound easy. How hard is it to send around little vans? But this scheme alone illustrates how significant operational issues are. Remember that nursing homes are having difficulty with vaccinations despite having a captive population. It isn’t just the complications with getting informed consent when a meaningful proportion of the residents are cognitively impaired. It’s that with the Pfizer and Moderna vaccines, the techs need to thaw and transport enough vaccine for that visit’s shots and no more. That means the nursing home needs to give an accurate count of how many are to be vaccinated that day. That apparently gets messed up frequently.

Let’s start with:

How do you identify which neighborhoods to visit and at what hours? And how many visits will it take to do the job?

How do you let the residents know when you will be there? Fliers in stores? TV and radio ads? Mailers?

How do your confirm eligibility if distribution is restricted?

Will patients sign up for a time slot? What happens if they are late?

Will the mobility restricted be able to get help getting to and from the truck?

How will the mobile clinics allow for anaphylaxis risk? The current practice appears to be to have patients wait 15 minutes after a shot to see if they are OK, and a half hour if they have a history of allergic reactions. Will the clinics provide chairs? What happens if it is cold or rainy and therefore not comfortable to wait?

What about second shots? Will patients get reminder calls, e-mails, and/or texts? Will the vans come back?

And Dr. Walensky plans to do serious empire-building. Again from the Journal:

Also among her top priorities, she said, are strengthening the nation’s public-health departments, which have suffered from years of funding and staff cuts, and modernizing the CDC’s outdated data systems.

Those steps will require substantial new funds from Congress. “I plan to be there often,” she said.

“We need to build a sustainable public-health infrastructure across the country, because one of the reasons that we’re in this mess is because we didn’t have it,” she said.

Huh? Is this ignorance or delusion? Public health is a state responsibility. From the NIH website, a lengthy appendix, Summary of the Public Health System in the United States, from the book The Future of Public Health:

States are the principal governmental entity responsible for protecting the public’s health in the United States. They conduct a wide range of activities in health. State health agencies collect and analyze information; conduct inspections; plan; set policies and standards; carry out national and state mandates; manage and oversee environmental, educational, and personal health services; and assure access to health care for underserved residents; they are involved in resources development; and they respond to health hazards and crises. (Hanlon and Pickett, 1984; Public Health Foundation, 1986b) States carry out most of their responsibilities through their police power, the power “to enact and enforce laws to protect and promote the health, safety, morals, order, peace, comfort, and general welfare of the people.” (Grad, 1981) In the tenth amendment of the U.S. Constitution, states and the people are designated as the repository of all government powers not specifically designated to the federal government. States, as sovereign governments, derive plenary and inherent power to govern from their people.

The appendix also describes the some of the various ways states organize their public health agencies.

The states are already unhappy at the way the Federal government has handled vaccine distribution. Even though many had made their problems worse by changing priorities on the fly, a big source of consternation is that Congress approved $9 billion of funding for vaccination programs in late December. The states would have needed to get the money in the spring or at worst the summer so as to staff up, procure supplies, and devise procedures to be ready now.

It’s one thing if Dr. Walensky were proposing block grants or Federal funds for specified public health improvements. Instead, she’s pumping for an unconstitutional land-grab. This is a prescription for generating hostility and range wars at a time when all officials, Federal, state and local need to be pulling together.

Fighting yesterday’s war. If you read the full article, what Dr. Walensky proposes would have been well and good as of say last October. Despite talking up the importance of vaccinations, she doesn’t acknowledge the acute stresses hospitals and medical professionals are under now, and her plans seem totally inadequate to the expected sharp rise in new infections thanks to more contagious Covid mutations.

Treating better PR as the solution to way too many problems. We pointed out during the Obama Administration that the Democrats saw better propaganda as the solution for every problem. Since PR won’t cure Covid, the Biden has had to moderate its expectations a tad. But they still place great faith in marketing. The Journal reports Dr. Walensky explaining that “Stopping the pandemic will require convincing people to wear masks and follow other measures to slow the virus.” Notice she does not suggest distributing free masks, which is deeply disturbing.

And I don’t see how you get through to mask refusniks. One friend rants about them and wears flimsy scarves over her mouth to feign compliance. Masks are now required indoors in Jefferson County, which includes my gym (which also strictly limits how many can come in at once, so it is always sparsely populated). I saw a young man wearing a mouth cover that was a joke, visibly open mesh over his face. I decided to take issue with his practice. I got a litany of excuses: he has asthma (sorry, friends with severe asthma mask up). He’d had Covid. Blah blah blah. A store employee at CVS always has her mask below her nose, despite CVS supposedly having a zero tolerance policy for employees and my having complained numerous times when I get a satisfaction survey, as well as a couple of times to store management.

And Dr. Walensky, and by extension, the Biden Administration, is in complete denial about anti-vaxxers. The Journal points out that a recent survey showed that 27% of the respondents aren’t planning to get the shots. From the article:

It is important for the CDC to reach out to people now who say they don’t want the vaccine, whether that is due to convenience or concerns about the science or of missing work, Dr. Walensky said.

“Right now is the time to do that outreach, to do that education, to understand why it is they may not want it and what it is that they need to understand in order to want it,” she said.

Help me. The assumption is the so-called vaccine hesitant are badly informed and if they are properly schooled, they’ll of course fall in line. Some of these individuals are anti-vaxxers and no amount of information will change their views. But Dr. Walensky does not seem to get that for plenty of others, doctors and Big Pharma are not seen as particularly trustworthy. Many patients see their primary care physician for only six or ten minutes, hardly enough to feel cared for. Doctors are doing squat to oppose the patient-rape known as balance billing. Big Pharma has brought us Vioxx, the opioid crisis, and Zantac, among other highly profitable patient catastrophes. Many doctors won’t prescribe new medications until they’ve been in use for six months or even a year. Treating individuals who are cautious as in need of indoctrination will only harden their views.3

On top of the 27% vaccine-reluctant, Kaiser found that 39% were in “wait and see” mode, holding back until they could ascertain how it worked for others.

If we just limit ourselves to the 27% and assume that at least that many won’t get vaccinated in 2021, the US won’t beat back Covid. The new variants with their higher R0s means a much higher proportion of the population would need to be vaccinated, say over 85%, for it to die out. In the meantime, we hear crickets from the CDC and the FDA about prophylactics and treatments.

Dr. Walensky is articulate and telegenic, so perhaps her main role is to rebrand the CDC while some deputies come in to do the heavy lifting of turning around the agency. If not, I’m not optimistic that the CDC will get back on track.

___

1 One of my favorite examples of how things ought to work, cribbed from Jonathan Glover’s carefully researched book, Humanity. And notice President Kennedy didn’t have to stoop to pulling the choke chain himself:

After the US blockaded Cuba, Khrushchev sent ships on course to Cuba, presumably to break the cordon. Secretary of State Dean Rusk asked the Admiral in charge of the operation what the Navy would do when the Russian ships approached. He was told they’d first make a shot across the bow. Rusk said asked what would happen next if the Russians were not deterred. The Admiral got testy and told Rusk that the Navy had been running blockades since 1812 and it was basically none of his business.

I can’t locate the book readily to give the exact wording but this is the spirit of Rusk’s dressing down:

This is not about your pettifogging naval traditions. The stakes are much higher than that. This operation is a means for the President to communicate with Khrushchev. You will remain in constant contact. You will not take a single action unless it has been explicitly authorized by the President. Have I made myself clear?

2 The only org chart box with that is even in the ballpark is “Center for Infection Control and Process Management” which reports to the SVP of Quality & Patient Safety. So I would hazard Dr. Walensky’s role was primarily research and teaching, and not much related to direct patient care.

3 We argued that the Obama Administration had given Warren this task on the assumption she’d flounder around, discredit herself, and then she’d be less of a problem to them.

3 A growing body of research has found that presenting people with information that contradicts their prior beliefs leads them to double down.

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40 comments

  1. The Rev Kev

    Whatever Dr. Walensky’s plans – and I do wish her well – the truth of the matter is that most of any plans for this year are going to be shaped by a bottle-neck which is the amount of vaccines being delivered. Everything to do with supply, distribution, facilities, military involvement, etc. will revolve around the rate that vaccines can be delivered for distribution. Patton’s offensive in Europe in WW2 got stopped because he did not have the gasoline to advance any further, in spite of having all the men, ammunition and equipment needed. This will be similar in that you may have the people, transport, facilities and all the rest of it but unless you have the vaccines, nothing else can get done.

    1. ambrit

      We must now also factor in the virus’s rate of mutation. If vaccine resistant strains arise, they will become the de-facto main strain quickly.
      I have always thought that this virus would end up functioning in a similar fashion to the “common cold” and the flu. Vaccines will become an annual need. Each year’s vaccine tailored to what the Ministry of Health guesses will be this years ‘popular’ varieties of Coronavirus.
      Below, find the CDC’s own figures for flu vaccine effectiveness, going back to 2004. As will be obvious, the annual efficacy of the flu vaccine is all over the place.
      See: https://www.cdc.gov/flu/vaccines-work/past-seasons-estimates.html
      Will future historians come to view the past year and the next few years as a “bottleneck” in the evolution of Terran Humans?

  2. doug

    Better PR is important. There has been little of it in USofA. We sell caramel flavored sugar water to folks that don’t need it. We can sell real ‘health care’ and the vaccines much better than is currently done.
    The Fed has shown PR can be effective.

    1. PHLDenizen

      Soda sells for about a buck per can — affordable by virtually everyone. It’s also surplus to needs. Seeing a doctor is not.

      “Real health care” is priced at stratospheric levels and is subject to your continued subjugation under the employer-based insurance regime. Lose your job, then you’re SOL. No amount of salesmanship is going to neutralize antipathy toward the healthcare industrial complex, inculcated by years upon years of profoundly awful experiences.

      It’s not unreasonable for people to fear balance billing or running afoul of complex eligibility requirements w.r.t. the vaccine. Covid isn’t sufficiently lethal enough to convince the destitute to wager the possibility of a relatively enormous bill. The uninsured have seen hundreds of thousands in bills for life sustaining Covid treatment, leading them to financial catastrophe. The Biden administration can promise them all he wants, but the government has nary a shred of credibility when POS’s like Richard Neal sink billing reform efforts.

      You also underestimate the level of resentment boiling over among the underclass toward the more affluent. Anecdotally, I’ve heard sentiments such as “the only reason they’re forcing this vaccine on me is so they can start going out to eat and on vacations again. Fsck ‘em. They’ve sacrificed nothing.” No amount of PR is going to undo damage inflicted by the sociopathic elites. I don’t blame them and neither should you. Calling them “ignorant anti-vaxxers” erases their legitimate grievances, which is exactly the problem.

    2. chrimbus

      I wish that PR was directed toward:
      – Caution about asymptomatic spread of covid
      – The timeline of the 2-dose MRNA vaccines (the importance of getting the 2nd one to make sure we aren’t giving covid a chance to adapt to a very partial antibody response).
      – Possibility that the vaccines won’t totally reduce one’s ability to carry / spread covid (w/o getting personally sick)

      None of these points are totally beyond the pale, but they need to be rehashed, since many of Our Institutions are content to proceed with the received wisdom of last spring (hygiene theater, the invocation of 6 feet, etc) unfazed by ongoing developments. Worse, the PR engine is focused on a combination of getting schools to open for in person instruction and to dodge the idea of closing (or slowing) any businesses.

  3. Phacops

    Perhaps the greatest cultural shock that Walensky will encounter I think is that in East coast ,elite institutions, people are protected from failure. Will she be able to gain compliance from other, independent, institutions that have other ideas for reaching public health goals.

  4. Carolinian

    As readers of this blog know, a lot of the vaccine hesitant are doctors. I think a lot of people are taking a wait and see attitude toward the rushed vaccine.

    1. Keith Newman

      I concur. I am a “wait and see-er”. The Pfizer and Moderna vaccines use new technologies and lack data on long-term effects. They introduce messenger RNA into the body’s cells to produce the Covid spike protein and that worries me. I believe the Janssen vaccine is a more standard kind. I’m waiting to be able to get that one, once it has been given to a few million people without an excessive number of “adverse events”.

      1. Carla

        We considered being test subjects in the Johnson & Johnson/Janssen vaccine trials. When contacted, we asked “If something goes wrong, what is Johnson & Johnson’s responsibility to us?” The answer was to the effect of “Treatment for any side effects you might encounter is between you and your health insurer.” Translation: you’re on your own. The screener said she would email each of us a pdf of the 29-page legal agreement we would have to sign detailing the limits of J&J’s (or Janssen’s) liability. I don’t know which because it was never sent to either of us.

        Needless to say, we never participated in the trials.

      2. fajensen

        We are out of time here. If you wait much longer one of the new and improved strains are going to get you before the vaccination.

        My wife went back to work on the 8’th of January, got ill Monday. Got worse during the week with dropping SPO2 levels, luckily she was not admitted to hospital when we went there to get their opinion, they estimated she would be better off at home.

        *All* of her colleagues had got it by Wednesday. In 3 days!

        I got ill Thursday in the sense that “something” is going on and now wife is better and I have the fever and breathing problems.

        I’d take the vaccination rather than risking two weeks of pure fear every time this crap comes round, which it will every 9 months thanks to the quackery of “heard immunity by natural infection”!

        We both had it in February 2019 too. Took me only 8 months to get part of my running form back.

    2. GM

      This is not the reason why they are hesitant, but with the new immune escape variants appearing now, one has to think long and hard about taking the vaccine. Here are the two preprints from yesterday:

      https://www.biorxiv.org/content/10.1101/2021.01.18.427166v1

      https://www.biorxiv.org/content/10.1101/2021.01.15.426911v1

      Basically even the South African variant alone (and presumably the one from Manaus too, as it shares the key mutations) may well make the current vaccines obsolete, and there will be further evolution after that.

      But then there is this obscure immunological concept called “original antigenic sin”, which refers to the tendency of the immune system to go back to whatever response it generated originally when it encounters a slightly different new version of that antigen.

      What that means in practice and in simple words is that the people who are being vaccinated now may soon find themselves in a situation in which vaccine-resistant variants are circulating but the updated vaccines don’t work on those already vaccinated against the original strain.

      In which case it makes sense to wait.

      But that assumes that there will not be further immune escape variants, which is not just an unwarranted assumption, it is in fact near certain to be wrong, there will be immune escape from the updated vaccines too.

      What do we do then?

      Which brings us back to the original fundamental problem — Western governments stubbornly insist on “solving” this problem with vaccination, because this is both an ideologically acceptable approach (“look how our private sector-provided technological might solved the problem”) and it does not require doing the hard work of eliminating the virus (which also cannot be accomplished without the absolutely heretical idea of downwards wealth redistribution).

      But the reality is that there is no real solution to this problem aside from elimination. This is not smallpox where you have a DNA virus and perfect sterilizing vaccines plus perfect sterilizing natural immunity. It’s a respiratory coronavirus for which natural immunity lasts a year or two at best and antigenic evolution can be quite rapid as we are seeing now.

      1. Yves Smith Post author

        You are neither telepathic nor omniscient and cannot speak for the entire profession.

        I am in contact with MDs working in hospitals. I have been told by individuals in different institutions that are holding back and report some peers and nurses are too due to 1. Established personal policy of never taking or prescribing any new medication, they prefer to wait at least 6 months for more use data to come in (which they admit puts them in a difficult position with patients since they do not want to talk them out of the vaccine, particularly given strong institutional pressure otherwise) and/or 2. Particular concern with novel mRNA technology.

  5. lyman alpha blob

    Speaking to that poor competence, many years ago now before the opioid crisis was a thing my wife’s doctor had her go to the emergency room for a fairly mild ailment. She told the doctor her pain was maybe a 2 maximum on a scale of 1 to 10, so far from debilitating. The nurse later hands her a mitt full of pills for the pain that wasn’t that bad in the first place. I believe it was oxycodone they said they were giving her, and I asked about it being highly addictive and was told that I must be thinking of oxycontin, but this was different and not addictive at all. I went home and looked it up, found out I was right and the medical professional handing out the addictive pills like candy was wrong, and we disposed of them without taking any. People are definitely correct to be wary of a medical system that places profits for pharmaceutical companies over people’s health. I definitely will not be the first in line to get a vaccine developed in a rush by for-profit US pharmaceutical companies that face no liability should anything go wrong.

    And to touch on this –

    …it involves coordinating across Federal agencies, with state and local governments, hospitals, and major pharmacy chains.

    – the fact that all of these hospitals are owned by different companies and are in different networks makes the logistics even more complicated. Imagine though if we had one national, state owned medical infrastructure, with all the distribution points belonging to one system, like the NHS in the UK. That would remove many of the logistical impediments we are facing. Maybe with a functioning health care system, we wouldn’t need to consider calling in the military to hammer down every perceived nail.

    Medicare for all would be a welcome improvement, but that’s just insurance and to me, it is the temporary compromise and not the desired end result.

    We need a true national healthcare system staffed with competent professionals and we need it yesterday.

  6. Tom Stone

    My sister is a retired nurse and nursing teacher.
    When I asked her if she were going to volunteer to help out she gave me a blunt NO!.
    When I asked her why she told me that she saw no use in committing suicide in a vain effort, that the response to Covid was so screwed up that it would do no good.
    She is 68 years old.
    A lot of the health care professionals who have retired will not come back because they have a realistic view of both the risks and how dysfunctional the health care system is.

  7. Socal Rhino

    There should be a way to coordinate federal efforts with the state health departments. I think of the insurance industry, also regulated state by state, with life insurance companies that don’t want to file 50 versions of annual filings. There is a national organization of insurance commissioners that has worked to standardize while leaving room for states to customize at the margins.

  8. Lee

    Here in California, I’ve got a 74 year old friend who works at Trader Joe’s. He’s a Kaiser health plan member. By age and occupation, he’s in one of the top tiers eligible to receive a vaccination. He has yet to hear a peep from either his employer or health care provider. I am of similar age, retired, and am a Stanford patient but Stanford too seems to be getting the mushroom treatment.

    According to the Alameda county website, 85 thousand initial doses have been given, and all of those to front line medical providers and long term care patients. In a county of 1.7 million, we’ve go a long way to go. Maybe the single dose vaccines that rely on normal refrigeration and older, more tested mechanisms of action will speed things up and help to allay public concerns regarding the new mRNA vaccines.

    1. curlydan

      I have 78 year old parents who seemingly can’t get anywhere near a vaccine in TX. If Israel’s experience is any guide, then it appeared they focused almost solely on age as a determinant for vaccines after medical providers.

      In Texas (and maybe now in much of the U.S.), the age range for the “tier 2” shots was expanded by the Gov to include 65+ and anyone with a large set of medical conditions, including obesity. There is no check on whether or not you actually have that medical condition either–although I guess obesity might be observable to some extent.

      The upshot is that my parents and their similar aged friends are looking everywhere trying to get a vaccine but are woefully unprepared to compete with the hordes of other, younger people trying to get a vaccine. 75+ year olds really aren’t that hard to find. They have drivers licenses and Medicare cards.

      The CDC has a huge problem on their hands and (I believe) some chaotic months ahead.

      1. curlydan

        and I do realize that Israel’s vaccination success excludes the Palestinians, so that success is obviously partial and exclusionary.

      2. Sharron

        In Texas no one reaches out to you via email. My husband was contacted via his healthcare portal at the medical system he gets his care from, that I just happened to notice. After I filled out all the online documents, I checked his portal(I don’t like doing text notifications for medical stuff) 2 to 4 times daily for about 2 weeks and finally found an available time for him. Very similar process for the metropolitan health department, to get a shot for myself.
        This is a very very unfriendly system for older people that are not tech capable. We had to drive 2 hours for my husbands shot and an hour for mine as there are NO vaccines available in rural Texas. Don’t they know most of my neighbors out here are republicans??? Not smart.

  9. Susan the other

    This is sobering. A good analysis of a gordian knot. And on top of all of this we are faced with the fact that the vaccine is only about as preventative as a yearly flu shot if enough people take it. Maybe Walensky is a distraction since the CDC is just a big accounting firm for health statistics. The NIH is into the science of disease control. The states are responsible for logistics. Providers are in it strictly for profit. And nobody’s on first. If Biden were serious about solving this mess he would not PR the CDC. He’d organize the “last mile” of the distribution process. But Biden has stated again and again that he is against national health service measures, and certainly against M4A. But then he campaigns on the blatant contradiction that “healthcare is a right.” He’s just ducking the mess he is in. I’m looking forward to his face plant.

  10. Alex Cox

    Regarding the first footnote, re. Kennedy being unafraid to overrule the Pentagon, less than a year later he was dead, shot (we are told) by a sniper trained by the USMC.

    Trump may have been afraid to contradict the Pentagon, but he leaves office alive…

  11. petal

    Having worked at Man’s Greatest Hospital for part of my career, when I finally left, stepping out of that bubble was like hitting a brick wall. You get used to having staff and coworkers as highly motivated(or more) as you are, access to all the latest resources and technology, and support staff. Things get taken care of so you don’t have to miss a beat. Reckon she is going to have a rude awakening in Atlanta, and when she goes to DC. She hasn’t been out in the real world.

    It looks like she was the ID division chief. Divisions are pieces under the “Department” umbrella, so she wasn’t even a department head, from what I can tell. Her specialty is HIV. I’ve seen an old roommate of mine with her in photographs of meetings(for the hospital’s covid response). I doubt that she has ever had to manage much of a staff.
    (sorry, am tired, so not writing well)

    1. Yves Smith Post author

      Thanks for weighing in. I posted a link to the Mass Gen org chart, and despite it showing many boxes, there’s no box for an “infectious diseases” department or division, if that’s the Mass Gen nomenclature. I’ll look again and see if I can guess where it might sit.

      1. petal

        Yves, earlier this afternoon before I posted I looked through the chart you posted and couldn’t find it. I even did an internet search, and there was no…way to tell which umbrella ID was under. It’s really weird. I found my old “group” and which dept it fell under, along with others in that same dept, but nothing for ID. I will try to think of someone I could ask.

          1. Yves Smith Post author

            If she’s a professor at Harvard, she has to be working there. Harvard lets faculty members have only 2 year sabbaticals max, then they lose their post. That was a decision Elizabeth Warren had to make after she was on the Congressional Oversight Panel. So it isn’t even clear how much time she was actually at Mass Gen, unless maybe some of her Harvard duties include running research at Mass Gen. Petal, any idea?

            1. petal

              So the thing with the biomedical appointments at HMS is that PIs or MDs located at Harvard-affiliated hospitals get HMS status whether they actively “teach” or not. My old boss, never taught a day in the years I was there. He ran a lab and we did research. But he has an HMS appointment. Same for a former colleague. He’s a surgeon at MGH but also has asst professor status at HMS because of the academic affiliation umbrella. Our lady in question could have done research or clinical work while working FT at MGH and been given an HMS appointment. MGH is your …clinical or research work position, while HMS is your academic appointment because due to your work position you’re also under the Harvard academic umbrella. That probably makes no sense…It’s a weird set-up. I don’t know how to explain it any better.

  12. Henry

    It’s a good thing the Math + prophylaxis protocol appears to work well even minus the ivermectin so we don’t have to rely on our government or healthcare system. My neighbors in their late 80s seem to have survived a bout of Covid perhaps from just being on the protocol. To be fair she was already on supplemental oxygen before being infected, but still symptoms no worse than the a bad flu though I wouldn’t advise waiting a week after showing symptoms to get tested, like they did, as now that NIH has decided it is ok to use ivermectin and that could have helped. It’s only been a month now so we’ll have to see and of course it is anecdotal so take it as you will.
    Here is a recently published preprint article on why niacin (Vit B3) is important:
    https://osf.io/uec3r/

    Bonus: Based on the way this works there is no reason it shouldn’t work equally well in preventing flu complications.

    1. john buell

      Mainstream media have ridiculed Trump for endorsement of hydroxychloropine, but there are numerous observational studies by top. notch scientists showing it is very effective when administered prophylactic or on early exposure to the virus. The drug is not patentable and thus not able to produce mega profits. Advisory committees stacked with scientists having a stake in other patented medications have ruled against HCQ. NC had a link to a great detailed essay on this. Unfortunately state medical boards make it hard for yoour physician to prescribe.
      T https://filiperafaeli.substack.com/p/yes-hydroxychloroquine-is-scientifically-c9e

    2. Dwight

      I think clinics where people test positive should be giving out or recommending these prophylactics, even w/o Ivermectin although it seems NIH has recognized value so states should stop interfering. Can’t hurt to get C, Zinc, and Quercetin into people. D also, and why wait until vulnerable people test positive? Why wasn’t everyone given Vitamin D blood tests as soon as this hit? Not saying it’s panacea but it could have helped many. Instead we just waited until inflammatory stage w/ no effort to limit viral replication. I know of case where clinic gave steroids which suppress immune system and aren’t indicated till inflammatory stage. Fortunately this person asked doctor who said don’t take it. Hope this is isolated case.

  13. Cuibono

    “The new variants with their higher R0s means a much higher proportion of the population would need to be vaccinated, say over 85%, for it to die out.”
    Is anyone suspecting this will die out? I was under the impression that SarsCov2 will become endemic.

    1. Yves Smith Post author

      If you get the effective R0 to below 1, whether through vaccination or previous infection or a combo, the infection does die out. That’s the whole point of “herd immunity”.

  14. Starry Gordon

    In regard to whether people will sign up for the vaccine, as soon as it became available in New York, it became nearly impossible to get regardless of one’s qualifications because so many wanted it; plus, the online program is a bureaucratic nightmare which will discourage many people. For instance, the state portal wants to know completely irrelevant things like your race and whether or not you’re Hispanic, and you have to type in the information over and over again although obviously a computer is perfectly capable of storing your data from session to session. (Many sessions will be required because at present it is almost certain you will not find any open appointment slots.) The state and city had months to prepare for this project, in an area where competent programmers are falling over one another in the streets. In any case the work is not advanced rocket science; a bright high school student could do it in a few weeks. We not only have the Deep State; we have the Deep Incompetence.

  15. VietnamVet

    The USA got away with having 50 different health departments and defunding federal health programs and not restocking PPE since the last big pandemic was hundred years ago. To control the coronavirus pandemic, the USA has to go on a war footing. The biggest problem is that the ruling neo-liberal cult deemed government irrelevant, markets determine value, useless except to bail out too big to fail corporations. But, only nations can fight pandemics by closing borders, marshaling resources and manpower, and providing a unified planning and command structure.

    The USA would never have defeated Imperial Japan with 50 National Guard armies commanded by 50 different Generals and industry not converted to war production.

  16. GM

    The new variants with their higher R0s means a much higher proportion of the population would need to be vaccinated, say over 85%, for it to die out.

    This is another case of deeply unfortunate and probably deliberate misinformation.

    R_0 is not a static number, it depends on behavior.

    The indications for the brief period of time in February 2020 when life was normal but the virus was spreading were that R_0 was in the range between 5 and 6. Which means 85% HIT.

    All those people quoting “60-70%” as the number all this time? They were either deliberately lying in order not to “cause panic” or they have no idea what they are taking about.

    That number is based on R_0 = 2.5-3.0. Which it has been but mostly with at least some form of social distancing, people scared, etc. But in reality it was a lot higher from the beginning, because if you want normal life back, you have to take into account the R_0 under the condition of nobody wearing masks, packed schools, gyms, stadiums, night clubs, restaurants, etc. And the new variants are adding on top of that.

    I personally have no doubt some of the “experts” misleading the public indeed lied deliberately. Fauci has at this point an established track record of doing precisely that.

    1. Yves Smith Post author

      I will admit to using “R0” as shorthand for “effective R0” but that’s an almost universal shortcoming.

      Moreover, we published links to studies of reasonable scale (not about to go digging now) that found an R0 of over 5, as I recall 5.4. That is precisely why I used 85% as a guesstimate, because that level of immunity is what you need if you have higher unmitigated R0s.

  17. rjs

    hope they’re ready to restart the pandemic response thing over again from the beginning:

    South African SARS-CoV-2 variant escapes antibody neutralization — Researchers in South Africa have conducted a study showing that the novel 501Y.V2 variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has emerged in the country is able to escape the neutralizing antibodies that are elicited by previously circulating strains of the virus. SARS-CoV-2 is the agent responsible for the coronavirus disease 2019 (COVID-19) pandemic that is currently sweeping the globe, devastating public health and the global economy.The study found that the 501Y.V2 lineage also conferred complete escape from three classes of therapeutic monoclonal antibodies.Penny Moore from the National Health Laboratory Service (NHLS) in Johannesburg and colleagues say the findings highlight the possibility of re-infection among people presumed to have acquired some degree of immunity due to previously having had SARS-CoV-2.The findings also have important implications regarding the effectiveness of certain vaccines and therapeutic strategies that are undergoing development. A pre-print version of the research paper is available on the bioRxiv* server, while the article undergoes peer review.

    this could give team Biden the opportunity to show they’re better than Trump, hindsight notwithstanding

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